Basic Information
| Provider Information | |||||||||
| NPI: | 1124406368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEVELOPMENTAL REHAB SERVICES,INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18643 CAMELLIA DALE TRL | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770844277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133202670 | ||||||||
| FaxNumber: | 7135837597 | ||||||||
| Practice Location | |||||||||
| Address1: | 18643 CAMELLIA DALE TRL | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770844277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133202670 | ||||||||
| FaxNumber: | 7135837597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2015 | ||||||||
| LastUpdateDate: | 05/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7133202670 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | OTR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 113673 | TX | N | Agencies | Home Health | 252Y00000X | 113673 | TX | N | Agencies | Early Intervention Provider Agency | 261QM0850X | 113673 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3425787-01 | 05 | TX | MEDICAID |